1
APPLICATION FOR FUNDING SUMMARY PAGE
(complete one for each program for which you are requesting funding)
REQUEST DATA
Program/Project Title
o
New
o Continuing
o
o
o
o
o
Area from which funding is requested
(select only one)
Total Budget for this Program/Project
$
Amount of this request
$
Geographic area served by this Program
Total number of people to be served
during grant period
If a continuing program, total number
served in this program in 2014 - 2015
Brief demographic description of
population served by this Program/Project
Brief summary description of program to be
funded.
1.
List 3 things you will do with United Way of
2.
Trumbull County funding
List 3 results you expect to achieve with
United Way funding.
List at least 3 major steps you will take to
achieve those results.
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3.
1.
2.
3.
1.
2.
3.
Income
Education
Health
Basic Needs
Reading Great by 8
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UNITED WAY OF TRUMBULL COUNTY
APPLICATION FOR 2015 – 2016 FUNDING
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TABLE OF CONTENTS
Program Funding Guidelines
Page 3
Tentative Calendar
Page 5
Certification Letter
Page 6
Application Cover Pages
Page 7
Application
Page 9
Required Attachments
Page 11
Document Checklist
Page 12
EXAMPLES OF DOCUMENTS THAT WILL BE REQUIRED AFTER
FUNDING IS AWARDED
Page 13
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4
PROGRAM FUNDING GUIDELINES
1. Program funding from the United Way of Trumbull County is made at the direction of
United Way’s Board of Directors and is for a one-year period beginning July 1, 2015 and
concluding June 30, 2016.
2. Funding from United Way of Trumbull County supports programming by agencies who
are involved in the provision of health or human services in the county of Trumbull and
who are eligible to received tax-deductible donations and with a focus on the areas of
Income, Education, and Health.
3. Funding will not be provided for:








Film, video, radio or television projects.
Endowments, vehicle purchase, capital expenses, debt reduction or budget deficits.
Political projects.
Religious organizations for religious purposes.
Grants or loans to individuals.
Short-term events such as conferences, festivals, fundraising functions, awards
programs.
Travel, tours or bus trips.
Sabbatical leaves, scholarly research, staff development.
4. Priority funding will be granted to:
a. Organizations that demonstrate best practices and achieve measureable results
b. Organizations that support our goals under the four United Way Impact areas and
the Reading Great by 8 Literacy Initiative
EDUCATION: Helping children and youth achieve their potential
 Improving access to quality, affordable childcare and early learning opportunities
 Partnering with schools and parents to improve graduation rates
 Providing after school and mentoring programs for at-risk youth.
Resources: 40 Elements of Healthy Development.
Trumbullmhrb.org -> ASAP->Trumbull County Drug & Crime Prevention Strategic Plan
INCOME: Helping families become financially stable and independent.
 Increasing financial literacy.
 Helping hardworking people obtain job training and family sustaining wages.
 Increasing affordable housing for seniors and families.
Resources: cfed.org
HEALTH: Improving peoples’ health.
 Increase access to critical healthcare services.
 Reduce substance abuse, childhood obesity and domestic violence.
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
Increase health education and preventative care.
Resources: Trumbull County Community Health Assessment. Tcbh.org/accreditation
Trumbullmhrb.org -> ASAP->Trumbull County Drug & Crime Prevention Strategic Plan
BASIC NEEDS: Programs and services that meet the basic needs of residents of Trumbull
County.



Shelter
Food
Emergency Services
READING GREAT BY 8 Literacy Initiative: The Reading Great By 8 Literacy
Initiative is designed to increase the number of Trumbull County children reading at
grade level by grade three, with an emphasis on children from low- to moderateincome families.
Requests for funding for Reading Great by 8 MUST include the pre- and post-test
instrument you will use to measure effectiveness.


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Out-of-school-time programs focused on measurably improving reading skills of children
ages 5 – 8.
Measurably reduce the effects of summer reading slide.
6
COMMUNITY INVESTMENT
TENTATIVE CALENDAR
February 13, 2015
Application forms available
March 27, 2015 by noon
Applications due at United Way
Week of April 6, 2015
Applications available to volunteers
Week of April 13, 2015
Volunteers review & score applications
Week of April 20, 2015
Panel meetings begin
Week of May 2, 2015
Panel meetings conclude
May 12, 2015
Recommendations to the Board of Directors
May 14, 2015
Notification to agency directors
July 1, 2015
Funding cycle begins
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CERTIFICATION LETTER
We hereby certify that the Board of Directors or governing body of ______________________________
Duly note that this Funding Request is presented to the United Way of Trumbull County for confidential
use in its funding process.
We agree and understand that any falsification of information herein, regardless of time of discovery, may
cause forfeiture on our part of any funding by United Way of Trumbull County.
We certify that, to the best of our knowledge, the organization has the financial capacity to deliver the
programs for the period of time covered by the application.
In addition, we certify that to the best of our knowledge, the information contained in this request is
accurate and that we are in compliance with all legislation, ordinance, codes, taxation laws, rules and
regulations applicable to not-for-profit organizations.
___________________________________________________________ __________________
Signature of Organization Chairperson, Board of Directors
Date
__________________________________________________________ ___________________
Signature of Organization CEO/Executive Director
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Date
8
2015 COMMUNITY INVESTMENT APPLICATION FOR FUNDING
ORGANIZATION NAME
Applicant Organization (Full Legal Name)
Doing Business As
Previous Name, if changed
IRS letter date
Tax Exempt ID # (EIN)
Name of Executive Director
CONTACT INFORMATION
Proposal Contact Name
Title
Phone
Fax
E-mail
Street Address
City
State
Zip Code
Organization Website
Mailing Address (if different than street address)
City
State
Zip Code
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9
ORGANIZATION FINANCIAL INFORMATION
Organization’s Budgeted Expenses for
Current Year (give fiscal year end mm/dd/yy)
$
Organization’s Major Funding Sources
(e.g., United Way, local community foundation,
county board of health, etc.) by percentage
ORGANIZATION’S AFFILIATION
Chapter of national or regional organization (specify):
REQUEST DATA
Program/Project Title
o
New
o Continuing
o
o
o
o
o
Area from which funding is requested
(select only one)
Total Budget for this Program/Project
$
Amount of this request
$
Income
Education
Health
Basic Needs
Reading Great by 8
Geographic area served by this Program
Total number of people to be served
during grant period
Brief demographic description of
population served by this Program/Project
SIGNATURES (both are required)
Signature of President/Executive Director
Signature of Board Chairman/President
Date
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10
SECTION TWO – ORGANIZATIONAL BACKGROUND
Section 2 should not exceed 2 pages in total. Responses should be typed, single-spaced,
single-sided and use 11 or 12-point type.
1. Brief description of current programs/projects and activities.
2. Evidence of organization’s overall effectiveness (please list achievement of specific
organizational or program goals).
3. Briefly describe how the goals and objectives of this program align with the agency’s primary
goals and objectives.
4. Description of population, geographic region or community served by this program.
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11
Sections 3 through 6 should not exceed four pages in total. Responses should be typed,
single-spaced, single-sided and use 11 or 12-point type.
SECTION THREE – STATEMENT OF NEED OR COMMUNITY BENEFIT
1. What is the problem or need that is unaddressed or unmet? Or what is the community
benefit that this program or project will impart?
2. What is the research, statistic(s) or evidence that shows this need or benefit exists?
SECTION FOUR – PROGRAM/PROJECT DESCRIPTION & METHODOLOGY
1. Description of program/project, including:
a. Summary description of overall program/project to be funded under this grant
b. Brief description of goals and objectives for program/project
c. Evidence of use of best practices (For example, is this program based on a program that has
been shown to be effective in other settings? Is it based on national standards?).
2. How and with whom will the organization collaborate on this particular program?
3. Why is your organization positioned to address this need or benefit (e.g., skills, location, etc.)?
4. Identify other, similar existing programs within the community and how your program is
different.
SECTION FIVE – EVALUATION AND RESULTS
1. How will the program be measured and who (e.g. staff, consultant, etc.) will measure it?
2. Summarize past quantitative and qualitative measurements of the program.
3. What is the number of unique clients/participants that you will serve during the term of this
proposal?
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4. What are the expected results of the program? (e.g. number of people who now access
critical healthcare services as a result of this program. E.g. number of participants who
have reduced their BMI.)
5. Semi-annual reports based on your answer to 3 and 4 are required and failure to
submit those by the date due may make your agency ineligible for future funding.
SECTION SIX – PROGRAM/PROJECT FUNDING PLANS
1. List of other funders to whom this current proposal has been and will be submitted. For each
funder, indicate amount requested and status of request (e.g. “to be submitted,” “pending,”
“funded,” or “declined”). If funded, specify amount of grant and date received.
2. Other anticipated funding for this current proposal including:
a. Earned revenue
b. In-kind support
c. Special events
d. Fundraisers, etc.
3. Describe plans and specific sources for future/long-term funding that include strategies for
continuation of the program without United Way funding.
4. How will United Way of Trumbull County funds be used? Be specific.
SECTION SEVEN – REQUIRED FINANCIAL ATTACHMENTS
1. Total organizational budget for current fiscal year including a column showing the
organization’s year-to-date status (budget vs. actual).
2. Program request budget for your entire program.
3. Most recently completed IRS Form 990.
4. Most recently completed audit if available, including auditor’s notes and management letter
if issued.
5. Statement of Revenue/Support and Expenses for your organization’s most recently
completed fiscal year.
6. Current Balance Sheet.
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SECTION EIGHT – CHECK LIST
Do not submit copies of the listed documents.
Check yes or no whether or not your agency has the following, Board Approved, on file and
available for review and return the completed form with your application
Yes ___ No __ Provides health or human services in Trumbull County in the State of Ohio and
is eligible to receive tax-deductible donations within the meaning of IRS Code
Section 170 © (1) or (2), which includes 501 (c)(3) organizations.
Yes ___ No __ Is governed by a volunteer board of directors consisting of members from the
general community.
Yes ___ No __ Has board meetings at least four times per year.
Yes ___ No __ Has at least one, paid full-time or FTE staff person(s).
Yes ___ No __ Has been in business at least 2 years.
Yes ___ No __ Measures and evaluates program effectiveness
Yes ___ No __ Has By-laws
Yes ___ No __ Has an affirmative action policy/non-discrimination policies.
Yes ___ No __ Provides Directors & Officers Insurance.
Yes ___ No __ Has liability insurance.
Yes ___ No __ Has fiscal policies and procedures.
Yes ___ No __ Has personnel policies and procedures.
Yes ___ No __ Has Articles of Incorporation
Yes ___ No __ Will conduct a workplace campaign to benefit United Way of Trumbull County.
DUE TO UNITED WAY OF TRUMBULL COUNTY NO LATER THAN NOON ON MARCH 27, 2015
The Common Grant Application is a collaborative effort of funder and nonprofit organizations working to build the
performance capability of the nonprofit sector in Ohio.
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COUNTERTERRORISM COMPLIANCE
In compliance with the spirit and intent of the USA PATRIOT Act and
other counterterrorism laws, the United Way of Trumbull County requests
that each funded service provider (“Organization”) certify that it is in
compliance with the United Way of Trumbull County and the United Way
of America’s (“UWA”) compliance program.
Organization Name: _________________________________________________________________
Check the appropriate box to indicate your compliance
with each of the following:
Comply
Do Not
Comply


This Organization does not, will not and has not knowingly
provided financial, technical, in-kind or other material support
or resources* to any individual or entity that is a terrorist or
terrorist organization, or that supports or funds terrorism.


This Organization does not, will not and has not knowingly
provided or collected funds or provided material support or
resources with the intention that such funds or material
support or resources be used to carry out acts of terrorism.




This Organization does not regrant to organizations,
individuals, programs and/or projects outside of the United
States of America without compliance with IRS guidelines.


This Organization takes reasonable, affirmative steps to
ensure that any funds or resources distributed or processed do
not fund terrorism or terrorist organizations.




This Organization is not on any federal terrorism “watch
lists,” including the list in Executive Order 13244, the master
list of specially designated nationals and blocked persons
maintained by the Treasury Department, and the list of
Foreign Terrorist Organizations maintained by the State
Department
This Organization does not, will not and has not knowingly
provided financial or material support or resources to any
entity that has knowingly concealed the source of funds used
to carry out terrorism or to support Foreign Terrorist
Organizations.
This Organization takes reasonable steps to certify against
fraud with respect to the provision of financial, technical, inkind or other material support or resources to terrorists and
terrorist organizations.
* In this form, “material support and resources” means currency or monetary
instruments or financial securities, financial services, lodging, training, expert advice or
assistance, safehouses, false documentation or identification, communications
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15
equipment, facilities, weapons, lethal substances, explosives, personnel, transportation,
and other physical assets, except medicine or religious materials.
I certify on behalf of the Organization listed above that the foregoing is
true.
Print Name: ____________________________________ Title: _________________________________
Signature: ______________________________________________ Date: _________________________
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SEMI-ANNUAL ORGANIZATIONAL CHECK-LIST
FOR THE AGENCY
Reporting Period: July 1, 2015 – December 31, 2015 ______
Reporting Period: January 1, 2016 – June 30, 2016 _______
Agency ____________________________________________________________
Internal/external scan
1.
2.
3.
4.
5.
6.
7.
Yes
No
If yes, please comment in this
space or in an attachment
Have there been changes in the
community you serve that effect
your proposed participants.?
Have there been changes in
regulations or other
oversight/accreditation bodies that
impact or create new challenges to
your agency?
Have there been changes in
funding from corporate
contributions, foundations or other
donors/funders that were
unexpected?
Has your organization experienced
unexpected capital expenditures?
Is your agency’s operating budget
off-target year-to-date as compared
to expectations?
Have there been unplanned
changes in the CEO/Director, CFO
or Board Chairperson positions?
Are there any significant issues that
affect your agency’s ability to
deliver the program(s) funded by
United Way of Trumbull County?
I verify the responses above are accurate.
___________________________________________ ______________________
Agency Executive Director/President/CEO
Date
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SEMI-ANNUAL REPORT
AGENCY
PROGRAM
Due Jan.
31, 2016
Dec. 31,
2015
PERIOD OF
YOUR
ANNUAL
GOAL FOR
THIS
PROGRAM
Due July
31, 2016
June 30, 2016
ACTUAL
TO DATE
ACTUAL
TO DATE
From Section 5, #3
# served
PROGRAM RESULTS
From section 5 # 4. Indicate the # of participants who have achieved the results
Proposed Results
Goal
Actual
1
2
3
4
Demographics of those served
Number of children served under the age
of 18
Number between ages 19 and 59
Number of seniors served over the age of
60
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Actual
18
# of female participants
# of male participants
SUBMITTED BY
DATE
PHONE #
Share any success story on results you have achieved on the back of this report.
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